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Interveiwing (1)456787678987899878uy.pptx
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- 2. Health Assessment Health assessmentis a systematic plan of care that identifies the specific needs of a client through the collection and analysis of the client’s data.
- 3. Health Assessment Components • HealthHistory • Physical Examination • Documentation of findings
- 4. Health Assessment Types Comprehensive Assessment; Involvesa detailed history taking and physical examination performed at the onset of care on admission to a hospital or long term care facility. It encompasses health problems, health promotion, prevention and risks. Problem based or focused Assessment; It involves history and examination that is limited to a specific problem or complaint. It is most commonly used in walk in clinics and emergency departments but can also be applied in outpatient settings.
- 5. Health Assessment Types Episodic/ followup/ongoing assessment. Usually done when a client is following up on with a health care provider. Shift assessment at handover is another form of this assessment and its purpose is to identify changes of the patient’s condition from the baseline. Screening Assessment: Is short, in expensive and focused on detection of disease.
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- 7. Phases of aninterview process Pre interaction Phase The nurse collects data from the medical record and reviews the patient’s history of medical illnesses or surgeries, current medication list, and problem list. Beginning Phase • The nurse initially introduces herself or himself by name. • States the purpose of the interview. • Asks the patient his or her preferred name. Ensuring privacy within the i.e. g by pulling drapes, closing doors, or moving to a remote area before proceeding is essential, especially considering confidentiality guidelines.
- 8. Phases of anInterview process Working Phase • The nurse asks specific questions • Two types of which are • Closed-ended (direct) questions • Yield “yes” or “no” answers. An example is “Do you have a family history of heart disease?”
- 9. Phases of anInterview process Working Phase • They are important in emergencies or when a nurse needs to establish basic facts. • Open-ended questions • They require patients to elaborate. • They are broad and provide responses in the patient’s own words. • They are key to understanding symptoms, health practices, and areas • requiring intervention.
- 10. Phases of anInterview Process Closing Phase • The nurse ends the interview by summarizing • States what the two to three most important patterns or problems • Asking patients if they would like to mention or need anything else. • The nurse also thanks patients and family members for taking the time to provide information.
- 11. History taking • Interviewingis the method by which health care providers take health histories and gather subjective data. Sources of Information / Data • The individual patient is considered the primary data source. • Charts and family members are considered secondary data sources. A reliable historian provides comprehensive information consistent with existing records. If information differs from past descriptions or details change each time, the patient may be unreliable or considered • an inaccurate historian.
- 12. Components of HealthHistory Demographical Data Demographical data include; • Name • Age/Date of Birth • Address • Gender • Religion • Tribe • Employment/Occupation • Next of Kin • Insurance details/ Payment Details. • Date of Admission
- 13. Components of HealthHistory Reason for Seeking Care/ Presenting Complaint (PC) • Begins with open-ended questions and asks patients to explain symptoms. • A complete description of the present illness is essential • Questions about symptoms (subjective sensations or feelings of patients in the categories below help the patient be specific and complete. • Location • Duration • Intensity • Description • Aggravating factors • Alleviating factors • Pain goal • Functional impairment.
- 14. Components of HealthHistory Common mnemonics used to remember the key elements of the presenting symptom(s) are; OLDCARTS • Onset, • Location, • Duration, • Character, • Associated/Aggravating factors, • Relieving factors • Timing • Severity PQRSTU • Provocative/Palliative, • Quality, • Region, • Severity, • Timing, • Understanding patient perception
- 15. Components of HealthHistory Review of Systems: • The review of systems is a series of questions about all body systems that helps to reveal concerns or problem • Nurses ask questions related to each body system (eg, cough in the respiratory system) systematically before proceeding to the physical assessment
- 16. Review of Systems •General Health State. Weight gain or loss, fatigue, weakness, malaise (feeling of discomfort), pain, usual activity, fever, chills, sleep patterns. Integumentary System: Ask About; - Skin Diseases and lesions (wounds, sores, ulcers) - Skin growths (abnormal skin formations), tumors, masses (ebizimba) - Excessive dryness, sweating, ordors - Pigment changes and discoloration - Rashes Pruritus (itching) - Frequent bruising - Scalp Itching - Hair (refers to all body hair) as about changes in texture, amount distribution. - Ask about frequency of nail care.
- 17. Review of Systems Head •Headache • Past significant trauma • Vertigo (dizziness) • Syncope (fainting) Eyes • Discharge • Pruritus • Lacrimation (excessive tearing) • Pain in the eyeball • Visual disturbances ( floaters, halos around lights or flashing lights) • Swelling around the eyes • Redness • Unusual sensations or twitching • Visual changes • Diplopia, blurring vision, photophobia • Difficulty reading • Use of protective eyewaer
- 18. Review of Systems Ears •Pain • Cerumen • Infection, earache • Discharge • Hearing Changes • Use of prosthetic devices • Change in balance • Tinnitus ( Ringing or cracking) Nose, Nasopharynx and Paranasal Sinuses • Discharge • Epistaxis • Sneezing • Obstruction • Sinus pain • Change ability of smell • Snoring • Pain over Sinuses
- 19. Review of System Mouthand Oropharynx • Sore Throat • Tongue or mouth lesion (abscess, sore, ulcer) • Bleeding Gums • Voice changes or hoarseness • Use of prosthetic devices (device built to replace a damaged part ( Dentures, bridges) • Altered taste • Dysphagia (difficulty swallowing) • Difficulty Chewing Neck • Lymph node enlargement • Swelling or masses • Pain/tenderness • Limitation of movement • Stiffness
- 20. Review of Systems Breast •Pain/Tenderness • Swelling • Nipple discharge • Change in nipples • Lumps, Masses, Dimples • Breast self examination (frequency, method) Cardiovascular System Heart - Palpitations - Chest Pain - Dyspnea ( shortness of breath) - Orthopnea (person must sit to breath) - Paroxysmal nocturnal dyspnea(PND) (periodic dyspnea during sleep) - Fat diet
- 21. Review of Systems CardiovascularSystem Perivascular Vascular - Coldness, Numbness - Discoloration - Peripheral Edema - Varicose veins (SWOLLEN DISTENDED VEINS) - Paresthesia (abnormal Sensations ) - Leg color Changes Respiratory System - Colds - Cough, nonproductive or productive - Hemoptysis ( coughing up blood) - Dyspnea ( short of Breath) - Night Sweats (excess sweating during sleep) - Wheezing - Stridor (abnormal, high-pitched, wheezing) - Pain on Inspiration or Expiration - Smoking history, exposure to smoke
- 22. Review of System GastrointestinalSystem - Change in Taste - Thirst - Indigestion or pain associated with eating - Pyrosis (burring sensation in esophagus and stomach with sour eructation (belching) - Dyspepsia (heartburn or bloating) - Nausea/Vomiting - Hematemesis ( vomiting blood) - Appetite Changes - Food Tolerance - Abdominal Pain
- 23. Review of Systems GastrointestinalSystem - Jaundice ( Yellowish color to skin and sclera) - Ascites ( Abnormal intraperitoneal fluid accumulation in abdominal cavity) - Bowel Habits - Flatus (gas in intestines or stomach) - Constipation - Diarrhea - Changes in stools (color, consistency) - Hemorrhoids ( Pain, Rectal Bleeding) - Diet
- 24. Review of Systems UrinarySystem - Characteristics of Urine (color, contents) - Hesitancy - Urinary frequency (in 24-hour period) - Urgency - Change in the urinary stream - Nocturia (Excessive urination at night) - Dysuria (painful urination ) - Flank pain ( Posterior portion of body between ribs and iliac crest) - Hematuria ( blood in Urine ) - Suprapubic pain - Dribbling or incontinence - Polyuria (excessive excretion of urine) - Oliguria (decreased Urination) - Pyuria ( White blood cells or pus in Urine)
- 25. Review of Systems Genitalia General -Lesions - Discharges - Odor - Pain, burning, pruritus - Painful Intercourse - Infertility - Family planning Men - Impotence - Testicular masses/pain - Prostrate problems - Change in sex drive Women - Menstrual history ( date of onset, last menstrual period (LMP), length of cycle) - Amenorrhea ( absent menstruation) - Menorrhagia ( excessive menstruation)
- 26. Review of System Genitalia/ Women - Dysmenorrhea ( painful menstruation) - Metrorrhagia ( irregular menstruation) - Dyspareunia (pain during intercourse) - Postcoital bleeding ( bleeding after intercourse) - Pelvic Pain - Genitalia self examination
- 27. Review of Systems MusculoskeletalSystem Muscles - Twitching - Cramping’ - Pain (myalgia) - Weakness Bones and Joints - Joint swelling, pain, redness, stiffness - Joint deformity - Crepitus (noise with joint movement ) - Limitations in joint range of motion - Interference with activities of daily living. Back - Pain - Limitation in range of motion - Interference in ADLs - Amount and kind of exercise
- 28. Review of systems CentralNervous System - Fainting episodes or loss of consciousness - Seizures (characteristics and how treated) - Dysphasia (impairment of speech) - Dysarthria ( poorly articulated speech) - Inability ti remember - Disorientation to person place and time. - Hallucinations Motor-Gait - Loss of coordinated movements - Ataxia (balance problems) - Paralysis ( partial or complete) - Paresis - Tic , tremor, spasm - Interference with ADLs
- 29. Review of Systems CentralNervous System Sensory - Paresthesia (abnormal sensations, e.g. “pins and needles” tingling, numbness) - Anesthesia ( absent sensation, location) - Pain (describe)
- 30. Review of Systems EndocrineSystem • Changing in skin pigmentation • Changes in or abnormal hair distribution • Sudden or unexplained changes in height or weight • Intolerance • Presence of secondary sex characteristics • Polydipsia ( excessive thirst) • Polyphagia ( excessive hunger) • Polyuria (excessive urine output) • Anorexia ( decreased appetite) • Weakness
- 31. Components of HealthHistory Past Health History • It includes the patient’s history of medical and surgical problems along with treatments and outcomes. • Some problems are acute, others resolve, and others are chronic. Past Medical History • Major illnesses, beginning in childhood including Heart disease, Hypertension, Diabetes, Kidney disease, HIV, Tuberculosis, Asthma
- 32. Components of HealthHistory • Hospitalizations including the number of admissions and reason for admission. • Medications includes; - Name, dosage and frequency of medicine, and reason for use, if not clear from other history. - Consider asking about medicines prescribed by other doctors. - Ask about over the counter medicines. - Ask about herbal medicines, vitamins, and nutritional supplements • Allergies • Immunizations; For adults, this includes flu, pneumonia, tetanus, hepatitis B, chickenpox (if they did not have chicken pox in childhood). - Also includes history of TB skin testing (PPD), and immunizations related to travel, foreign residence, or occupation/avocation. (For example, yellow fever).
- 33. Components of HealthHistory Past Surgical History • Surgeries including; • Significant injuries ; - Injuries resulting in significant disability or altered activity. - Fractures, significant soft tissue injuries, concussions, motor vehicle accidents. • Transfusions
- 34. Components of healthHistory Gynecologic and obstetric (women) • Important to inquire about LMP (last menstrual period) in women of childbearing age. • Age at menarche (when periods began); frequency of periods; duration of flow. • Use of birth control in reproductive age women. • Number of pregnancies, children, method of delivery (vaginal or cesarean section). Psychiatric history • Information about any previous psychiatric conditions, diagnoses, hospitalizations, and treatments (including medications and psychotherapy)
- 35. Components of HealthHistory Family History • Questions about the health of parents, grandparents, siblings, and children help identify those diseases for which patients may be at. Important familial conditions include; • High blood pressure • Coronary artery disease, • High cholesterol, • Stroke • Cancer • Diabetes Mellitus • Obesity • Alcohol or Drug Addiction, • Mental illness • Genetic conditions.
- 36. Components of HealthHistory Functional Health Assessment/ Social History Functional health patterns; especially important to nursing, focus on the effects of health or illness on quality of life. The nurse assesses overall psychosocial well-being, including; • Hobbies and Habits • Eating and sleeping Habits • Living conditions • Self-perception/self-concept • Role/relationships
- 37. Components of HealthHistory • Coping/stress tolerance. • Spirituality and belief systems the nurse explores specific spiritual or religious preferences rituals, and practices that improve health status
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Editor's Notes
- #7 The beginning phase may continue with discussion of neutral topics (eg, the weather) if the patient seems anxious. The nurse shakes hands if that seems comfortable with the patient and is appropriate for culture and setting.
- #13 Presenting complaint is the summary of the problems in chronological order Eg Headache x2/7 Vomiting x 1/7 History of presenting complaint This provides the detailed explanation and description of the symptoms. It also includes what interventions have been done both at home and in clinics to alleviate the problem
- #32 For people on many medicines, good idea to ask them to bring medicines in.